Prevalence and risk factors for multidrug resistant uropathogens in ED patients.

The purpose of this study was to describe resistance patterns of infecting organisms and determine risk factors for multidrug resistance in patients with urinary tract infections. Retrospective case series of 435 patients age > or =16 with urinary tract infection. Multidrug resistance was defined as resistance to > or = two classes of antibiotics. Demographic, historical, and microbiological data were collected. Univariate analysis and multivariate logistic regression were used to determine risk factors for multidrug resistance. Multidrug resistance was seen in 37% of isolates. Univariate analysis revealed numerous associations with resistance. Multivariate analysis found three independent factors associated with multidrug resistance: urinary catheter use (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.4 to 4.8), age > or = 65 years (OR 3.0, 95% CI 1.7 to 5.4) and antibiotic use (OR 4.6, 95% CI 2.8 to 7.5). Diabetes was also a risk factor when patients with urinary catheters were excluded (OR 2.4, 95% CI 1.1 to 5.3). Resistance was seen in all groups of patients, but was particularly common in older patients and those who used a urinary catheter. Antibiotic use was highly associated with multidrug resistance.

Trimethoprim-sulfamethoxazole resistance among urinary coliform isolates.

OBJECTIVE: A large majority of urinary tract infections are caused by coliform organisms. Trimethoprim-sulfamethoxazole (TMP-SMX) resistance among uropathogens is increasing in many areas. The objective of this study was to determine risk factors for TMP-SMX-resistant coliforms in patients with urinary tract infections. DESIGN: Retrospective case-control study. SETTING: Emergency department of a tertiary care university hospital. PATIENTS: We studied 448 emergency department patients aged 14 years or older with a urinary tract infection caused by a coliform organism. Cases consisted of all patients with a culture-documented urinary tract infection caused by a TMP-SMX-resistant coliform, while control patients were those with a TMP-SMX-sensitive organism. MEASUREMENTS AND MAIN RESULTS: A univariate analysis of clinical variables associated with TMP-SMX resistance was performed. Multiple logistic regression was performed to determine independent predictors of TMP-SMX resistance. Resistance to TMP-SMX was seen in 15% of isolates. Numerous variables were associated with TMP-SMX resistance on the univariate screen. Independent predictors of resistance were diabetes (odds ratio [OR] 3.1; 95% confidence interval [CI] 1.2, 8.4), recent hospitalization (OR 2.5; 95% CI 1.1, 5.7), current use of antibiotics (OR 4.5; 95% CI 2.0, 10.2), and recent use of TMP-SMX (OR 5.1; 95% CI 2.2, 11.5). When those with recent hospitalization were excluded from analysis, independent predictors were current use of any antibiotic (OR 3.5; 95% CI 1.4, 8. 4) and recent use of TMP-SMX (OR 5.9; 95% CI 2.4, 14.3). CONCLUSIONS: Coliforms resistant to TMP-SMX are common in our emergency department. Diabetes, recent hospitalization, and the use of antibiotics, particularly the use of TMP-SMX, are independent risk factors for TMP-SMX resistance. Clinicians should consider these findings when deciding on antimicrobial therapy for patients with urinary tract infections.

Anxiety levels in EMS providers: effects of violence and shifts schedules.

We tried to measure anxiety levels in emergency medical service (EMS) providers to determine the effects of (1) having had a violent encounter during a shift and (2) different shift schedules, conducting a prospective observational study over 3 months in an urban EMS system setting. A convenience sample of 23 EMTs and 40 EMT-Ps was observed. Anxiety levels were measured using the Spielberger State-Trait Anxiety Inventory. A total of 99 inventories were completed by 63 EMS providers. The mean state (32.6+/-8) and trait (31.7+/-7.1) scores were less than normative scores (35.7+/-10.4 and 34.9+/-9.2 respectively) for working adult males (P = .004 and .007, respectively). Paramedics had lower anxiety scores than basic EMTs (P = .015 and .039) and years of experience also decreased anxiety scores (P < .0001). There was no significant difference in state scores between those EMS providers who had encountered violence during the preceding 12 hours and those providers who had not. Comparisons of state scores of providers assessed at hour 12 of a 12 hour shift, hour 12 of a 24 hour shift, and hour 24 of a 24 hour shift failed to show any significant differences. Although the working environment of the EMS provider contains numerous stressors and uncertainties, this population of providers were no more anxious than the general working public. Advanced training and years of experience decreased anxiety. Violent encounters during a shift did not appear to affect anxiety levels. There was no difference in anxiety levels in providers who worked 12 and 24 hour shifts.

Appropriateness of vancomycin use in the emergency department.

STUDY OBJECTIVE: The emergence of vancomycin-resistant organisms is a major problem at many hospitals. Vancomycin use is associated with development of resistance. The objective of this study was to determine the appropriateness of vancomycin use in the emergency department. In addition, we sought to determine whether appropriateness of vancomycin use increased after the publication of the Centers for Disease Control and Prevention guidelines for prudent vancomycin use. METHODS: This retrospective study was conducted at a tertiary care university hospital, and all patients who received vancomycin while in the ED during the first 6 months of each year from 1995-1997 were eligible for study. We developed appropriateness criteria based on national and local guidelines. Vancomycin use was determined to be appropriate or inappropriate according to these guidelines. RESULTS: Vancomycin use increased each year of the 3-year study period; 40% of use was considered inappropriate. However, appropriateness increased in a linear fashion (P <.001). A resistant organism was cultured from 17% of those with appropriate use and none of those with inappropriate use. Most patients, regardless of the appropriateness of drug use, continued to receive vancomycin after admission. CONCLUSION: Overall vancomycin use rose each year despite an increase in the proportion with appropriate use. However, inappropriate use remained common. Emergency physicians and consultants should become familiar with national and local guidelines for prudent vancomycin use.

Randomized clinical trial of melatonin after night-shift work: efficacy and neuropsychologic effects.

OBJECTIVE: Melatonin has received considerable publicity for its sleep-promoting properties; however, there is little scientific evidence of its efficacy. The objective of this study is to determine whether there are measurable beneficial effects from exogenous melatonin in emergency physicians after intermittent night-shift duty. METHODS: This randomized, placebo-controlled, double-blind, crossover trial was conducted in the emergency department of an urban tertiary care hospital. Fifteen emergency physicians were given melatonin 5 mg or placebo for 3 consecutive nights after night-shift duty with crossover to the opposite agent after a subsequent block of night shifts. The primary outcome measure was the global assessment of recovery measured by a visual analog scale. Secondary outcome measures included sleep quality, duration, and tiredness. In addition, the Profile of Mood States questionnaire and neuropsychologic testing were performed. RESULTS: There was no difference between melatonin and placebo in the global assessment of recovery (60.4+/-16.9 and 58.9+/-14.5, respectively; P=.29). There were no differences in sleep quality, duration or tiredness scores, sleep latency, hours of sleep obtained per night, and night or early awakening at any measurement point. Profile of Mood States and neuropsychologic test performances were similar. CONCLUSION: We found no beneficial effect of melatonin on sleep quality, tiredness, or cognitive function in emergency physicians after night-shift duty. Our results suggest that exogenous melatonin is of limited value in recovery from night-shift work in emergency physicians.

Prospective field study of violence in emergency medical services calls.

STUDY OBJECTIVE: To investigate the nature and frequency of violence encountered by EMS personnel. DESIGN: We conducted a prospective, observational case-series study of a city-county EMS system serving a population of 500,000. RESULTS: We analyzed 297 EMS runs over 737 hours of observation. The Overt Aggression Scale (OAS) was used to assess each violent episode. There were 239 (81%) nonviolent runs, 16 (5%) violent runs, and 42 (14%) violent runs that occurred after a violent episode had taken place (postviolent runs). This was a frequency of one violent episode for every four 12-hour shifts, or for every 19 runs. The violent behaviors included verbal aggression solely in 50% (n = 8), physical aggression solely in 13% (n = 2), and both verbal and physical aggression in 38% (n = 6). One episode involved an unsecured weapon. CONCLUSION: These data indicate that violent situations occur in 5% of calls in this EMS system. The fact that an additional 14% of calls are precipitated by the results of violence may influence perceptions by EMS personnel of danger and frequency of exposure to unstable situations. Exposure to violence is underreported in our EMS documentation.

Clinical presentation and outcome of brown recluse spider bite.

STUDY OBJECTIVE: To examine the clinical presentation and outcome of patients treated in the ED or toxicology clinic for suspected brown recluse spider bites. METHODS: We assembled a retrospective case of patients at a southeastern US university hospital. Our study group comprised 111 patients with suspected brown recluse spider bites treated during a 30-month period. Our main outcome measures were the need for skin grafting and the development of other complications. RESULTS: The mean age of our subjects was 34 +/- 17 years. Thirteen patients (12%) brought the spider to the hospital, 22 (20%) saw a spider at the time of the bite, and an exclusively clinical diagnosis was made in the remaining 76 (68%). Most wounds (59%) involved the leg. At the time of presentation, 81% had central discoloration and 37% necrosis. Sixteen patients (14%) were systemically ill, and 6 (5%) were admitted to the hospital. Most (86%) were treated with antibiotics. Dapsone was infrequently used (9%) and had usually been prescribed before the patient's presentation to our ED. Only three patients (3%; 95% confidence interval, 1% to 8%) required grafting. Mild hemolytic anemia developed in one patient, and another had mild hemolysis and a mild coagulopathy; neither patient was taking dapsone. No deaths or serious complications occurred in our study group. CONCLUSION: In our series, long-term outcome after brown recluse spider bite was good. Serious complications were rare, as was the need for skin grafting. Because the vast majority of bites heal with supportive care alone, aggressive medical therapy does not appear warranted.

Pediatric drug therapy in the emergency department: does it meet FDA-approved prescribing guidelines?

To determine how often Food and Drug Administration (FDA)-approved age-specific prescribing guidelines were followed in pediatric emergency department (ED) patients, the charts for all children presenting to a university hospital pediatric ED during a 30-day period were reviewed. Of the 359 children who received drug therapy in the ED, 43% received one or more drugs not approved for use at the patients' respective ages. Of 296 children discharged with one or more prescriptions, 16% received a drug prescribed outside of FDA-approved guidelines based on age criteria. Overall, 34% of children who received drug therapy in the ED or by prescription did not meet age-specific FDA-approved prescribing guidelines. The medications most commonly given outside FDA-approved guidelines were bronchodilators, benzodiazepines, and narcotic analgesics. Drug therapy in pediatric ED patients often falls outside FDA-approved prescribing guidelines.

Usefulness of blood cultures in pyelonephritis.

To evaluate the usefulness of blood cultures in patients admitted with pyelonephritis, a retrospective chart review was-conducted of inpatients at a 594-bed urban, academic medical center from 1990 through 1992 with a primary discharge diagnosis of pyelonephritis. A total of 338 patients had this primary discharge diagnosis. One or more sets of blood cultures were obtained in 307 patients (91%). Fifty-six (18%) patients had a positive blood culture; 24 (32%) positive blood cultures grew coagulase-negative Staphylococcus species, in all but two instances considered a skin contaminant. Of the blood cultures drawn, only 1 (0.2%) grew a pathogenic organism not found in the urine culture, with no impact on clinical management. These results support the conclusion that blood cultures are rarely clinically useful and seldom vary from urine culture results. Potential annual cost savings of between $10 million and $20 million in the United States could result from eliminating routine blood cultures in the setting of uncomplicated acute pyelonephritis.

Feedback to emergency medical services providers: the good, the bad, and the ignored.

HYPOTHESIS: To determine the type and frequency of immediate unsolicited feedback received by emergency medical service (EMS) providers from patients or their family members and emergency department (ED) personnel. METHODS: Prospective, observational study of 69 emergency medical services providers in an urban emergency medical service system and 12 metropolitan emergency departments. Feedback was rated by two medical student observers using a prospectively devised original scale. RESULTS: In 295 encounters with patients or family, feedback was rated as follows: 1) none in 224 (76%); 2) positive in 51 (17%); 3) negative in 19 (6%); and 4) mixed in one (< 1%). Feedback from 254 encounters with emergency department personnel was rated as: 1) none in 185 (73%); 2) positive in 46 (18%); 3) negative in 21 (8%); and 4) mixed in 2 (1%). Patients who had consumed alcohol were more likely to give negative feedback than were patients who had not consumed alcohol. Feedback from emergency department personnel occurred more often when the emergency medical service provider considered the patient to be critically ill. CONCLUSIONS: The two groups provided feedback to emergency medical service providers in approximately one quarter of the calls. When feedback was provided, it was positive more than twice as often as it was negative. Emergency physicians should give regular and constructive feedback to emergency medical services providers more often than currently is the case.

Interaction between the trauma team and families: lack of timely communication.

Families of critically ill patients desire early information regarding the condition of their relative. The purpose of this study was to determine how long family members waited before someone from the trauma team met with them to discuss the condition of their relative. This was a prospective, single-blinded study of a convenience sample of 63 trauma patients conducted at a trauma center. Observers recorded the time of arrival of the patient, time of family arrival, and the time the family was first contacted by the trauma team. Families arrived 38 +/- 35 minutes after the patient. The mean time families waited before contact with the trauma team was 37 +/- 34 minutes. This study shows that the trauma team is often slow in communicating with the family of the victim. One member of the caregiving team should be designated to advise the family on the condition of the patient as soon as possible.

Alcohol, the elderly, and motor vehicle crashes.

To document the prevalence of alcohol or drug use among elderly drivers admitted to a Level 1 trauma center after motor vehicle crashes, charts from 180 drivers age 60 years or older who were admitted to an urban Level 1 trauma center after motor vehicle crashes were retrospectively reviewed. Overall, 14% of the patients had a positive blood alcohol screen; among men, 21% had a positive screen. Only 55% of the patients were discharged to home. Only one patient ( < 1%) had a toxicology screen positive for another drug abuse. Alcohol/drug abuse counselling was offered to only one patient. These results suggest a relatively of high prevalence of alcohol use in elderly drivers involved in motor vehicle crashes, particularly men. However, abuse of other drugs was uncommon. Physicians treating intoxicated drivers should consider referral for alcohol counselling.

Compliance with recommendations for universal precautions among prehospital providers.

STUDY OBJECTIVE: To evaluate the compliance of emergency medical responders with local employer and Centers for Disease Control and Prevention recommendations for disposal of sharps and use of personal protective equipment in the prehospital environment. DESIGN: Prospective, single-blinded observational study of 297 ambulance runs conducted for 3 months. SETTING: A metropolitan emergency medical service system. PARTICIPANTS: Sixty-nine emergency medical technicians and paramedics. INTERVENTIONS: None. RESULTS: Observers recorded the handling of sharps and the use of personal protective equipment in four situations: i.v. line placement, endotracheal intubation, large-wound management, and body fluid hazard. Emergency medical workers properly handled sharps in 24 of 65 situations (37%). They were usually compliant with glove use during the observed procedures. However, compliance with the use of other personal protective equipment was poor. CONCLUSION: Sharps were often improperly handled. Most workers complied with recommendations for the use of gloves but often underused goggles, masks, and gowns. Although education and restructuring of the environment and equipment may improve compliance, strong consideration should be given to developing standardized and more practical recommendations for the prehospital environment.

The technique of managing asystole. High-dose or standard-dose epinephrine: which is better?

Early, aggressive treatment is essential if patients with asystolic cardiac arrest are to survive. To maximize chances for success, use a five-phase protocol. Phase I: Confirm the diagnosis with a series of checks. Phase II: Intubate and hyperventilate the patient with 100% oxygen. Use an end-tidal carbon dioxide (ETCO2) detector to confirm tracheal intubation. Phase III: Initiate therapy with 1 mg of epinephrine and 1 mg of atropine. Consider defibrillation with a 360-wsec shock to reverse occult ventricular fibrillation. Phase IV: Repeat doses of epinephrine and atropine every 3 minutes. Phase V: Reevaluate the patient's chances of survival. If ETCO2 levels are undetectable or barely detectable (below 0.5%), survival is unlikely.

The technique of reversing ventricular fibrillation: improve the odds of success with this five-phase approach.

Early, repeated defibrillation is the key to managing ventricular fibrillation (VF). To maximize the likelihood of success, use this five-phase approach, modified from the advanced cardiac life support protocols. Phase I: When a patient is found in VF and with no pulse or signs of life, attempt electrical reversion with a 200-wsec shock, followed if necessary by a 300-wsec and a 360-wsec shock. Phase II: Manage reversible causes of VF with orotracheal intubation, hyperventilation, and epinephrine. Phase III: Use intravenous lidocaine aggressively, followed by a 360-wsec shock. Phase IV: Give bretylium and magnesium sulfate by intravenous push, again followed by a 360-wsec shock. Phase V: Treat refractory VF with repeated 360-wsec shocks, and give further doses of the anti-arrhythmic agents.

Multicenter study of a portable, hand-size, colorimetric end-tidal carbon dioxide detection device.

STUDY OBJECTIVES: To evaluate continuous, semiquantitative end-tidal carbon dioxide (ETCO2) monitoring in the prehospital and emergency department setting for confirming proper endotracheal tube placement and assessing prognosis and blood flow during CPR. TYPE OF PARTICIPANTS: Adult patients were included if an endotracheal tube was inserted by prehospital care providers or emergency physicians for cardiac arrest, respiratory arrest, respiratory insufficiency, or airway protection. DESIGN AND INTERVENTIONS: A small, portable, colorimetric ETCO2 detector was attached to the endotracheal tube immediately after each attempted endotracheal tube insertion. The color of the detector membrane was noted at the seventh breath following intubation. The color also was noted and recorded if there was return of spontaneous circulation (defined as a palpable pulse) immediately prior to and following conversion from manual to mechanical CPR. Survival to hospital admission was used as an end point to assess the prognostic value of the initial ETCO2 reading. MAIN RESULTS: A total of 227 patients (144 with cardiopulmonary arrest) were studied. In the 83 patients intubated but not in cardiopulmonary arrest, a reading on the ETCO2 detector signifying more than 0.5% ETCO2 was 100% sensitive and 93% specific in detecting proper endotracheal tube placement (100% specific with the endotracheal tube cuff inflated). In cardiac arrest patients, a longer period of estimated arrest appeared to be associated with a lower ETCO2 detector reading. A reading signifying more than 0.5% ETCO2 was 69% sensitive and 100% specific in detecting proper endotracheal tube placement. After proper endotracheal tube placement, all cardiac arrest patients who survived to hospital admission had an initial ETCO2 measurement signifying more than 0.5% ETCO2. Return of spontaneous circulation was usually accompanied by an improved ETCO2 value. Mechanical CPR always produced an ETCO2 value that was as high or higher than that produced by manual CPR. CONCLUSION: The colorimetric ETCO2 device is highly accurate for confirming endotracheal tube position in nonarrest patients. CONCLUSION: The colorimetric ETCO2 device is highly accurate for confirming endotracheal tube position in nonarrest patients. In cardiac arrest patients, a reading signifying more than 0.5% ETCO2 confirms correct endotracheal tube placement, while a value signifying less than 0.5% ETCO2 during resuscitation suggests that something is wrong (eg. esophageal intubation, inadequate circulatory flow, prolonged down-time interval, hypothermia, or significant ventilation/perfusion mismatch).